Nurse Navigator

Job DetailsJob Location: Oklahoma City, OK 73118Position Type: Full TimeCare Coordinator / Nurse Navigator (LPN) Post-Acute & Hospital Transitions Specialist Position Summary The Care Coordinator / Nurse Navigator (LPN) supports safe, efficient transitions between skilled nursing facilities (SNFs), nursing homes, and hospitals by coordinating care plans, improving communication between providers, and reducing avoidable readmissions. This role serves as a clinical liaison across care settings and helps ensure continuity, compliance, and patient-centered outcomes during transitions of care. This position requires an experienced LPN with direct SNF/nursing home background and strong working knowledge of post-acute workflows, discharge planning, and regulatory expectations. Key Responsibilities Transition-of-Care Coordination Coordinate patient transfers between SNFs, hospitals, and post-acute providers Perform admission and readmission transition reviews Ensure completion and accuracy of transfer documentation Support safe discharge planning from hospital to facility Assist with high-risk patient tracking and follow-up Clinical Communication & Liaison Support Serve as liaison between: facility nursing teams hospital case management attending providers medical directors therapy teams Communicate changes in condition to appropriate stakeholders Support implementation of provider care plans across settings Readmission Prevention Identify patients at high risk for hospitalization Monitor early warning indicators: falls infections medication changes decline in functional status abnormal vitals/labs Coordinate early intervention strategies with providers and facility teams Documentation & Compliance Review transfer packets for completeness and accuracy Ensure continuity of: medication reconciliation code status advance directives diagnoses and problem lists Support regulatory compliance with CMS transition-of-care expectations Facility Collaboration Participate in: IDT meetings QAPI initiatives readmission review processes Assist facilities in improving transition workflows Support communication with corporate clinical leadership when needed Patient & Family Support Provide education regarding transition expectations Assist families navigating movement between care settings Reinforce discharge instructions and follow-up plans QualificationsRequired Qualifications Active Licensed Practical Nurse (LPN) license Minimum 2–3 years experience in skilled nursing facility or nursing home setting Direct experience with: hospital transfers admissions/readmissions discharge coordination change-of-condition workflows Strong understanding of post-acute documentation requirements Ability to communicate effectively across multidisciplinary teams Preferred Qualifications  Experience working with: post-acute provider groups medical directors hospital case management teams Familiarity with: INTERACT tools CMS readmission initiatives QAPI reporting EMR navigation across multiple systems Prior care coordination or navigator experience